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Interactive case studies

Interactive case studies. Swisstransfusion, 6 September 2013 Haemovigilance M. Jutzi, M.Rüesch Clinical Reviewer Haemovigilance, Swissmedic. Case 1.

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Interactive case studies

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  1. Interactive casestudies Swisstransfusion, 6 September 2013 Haemovigilance M. Jutzi, M.Rüesch Clinical Reviewer Haemovigilance, Swissmedic

  2. Case 1 A 42-year-old patient with AML developed generalised urticaria, angio-oedema of the lips, difficulties swallowing, and abdominal pains 5 minutes after the beginning of a platelet transfusion. This was accompanied by tachycardia (133/min) and hypotension (85/50 mmHg). No bronchospasm observed. What are your thoughts ? Hypotensive TR Allergic TR Not transfusion related Swisstransfusion, 06.09.2013

  3. Case 1 A 42-year-old patient with AML developed generalised urticaria, angio-oedema of the lips, difficulties swallowing, and abdominal pains 5 minutes after the beginning of a platelet transfusion. This was accompanied by tachycardia (133/min) and hypotension (85/50 mmHg). No bronchospasm observed. What are your thoughts ? Hypotensive TR Allergic TR Not transfusion related Swisstransfusion, 06.09.2013

  4. Case 1 • A 42-year-old patientwith AML developedgeneralisedurticaria, angio-oedemaofthelips, difficultiesswallowingand abdominal pains 5 minutes after thebeginningof a platelet transfusion. This was accompaniedbytachycardia (133/min) andhypotension (85/50 mmHg). • The bloodpressurednormalisedwithin 15 minutesofadministrationofantihistamines, corticosteroidsandinfusionof 500 ml ofsaline. Noneedforadrenaline. • Nootherconcomitantmedicationthatcouldhavecaused an allergicreaction. • Tryptaseelevatedto 39.3 ng/ml • IgA-level normal (determinedbefore transfusion) • Previousplatelettransfusionsuneventful • KnownallergytoImipenem Swisstransfusion, 06.09.2013

  5. Case 1 Howwouldyouclassifythisreaction ? Hypotensive TR Allergic TR Not transfusion related Swisstransfusion, 06.09.2013

  6. Case 1 Howwouldyouclassifythisreaction ? Hypotensive TR Allergic TR, anaphylactic Not transfusion related grade 3 Severity: Imputability: probable • Preventive measures for the future: • premedication with antihistamines and steroides • closer observation of the patient during transfusion Swisstransfusion, 06.09.2013

  7. Case 2 An 86-year-old patient with anaemia following diverticular haemorrhage (Hb 66 g/L) receives a RBC-transfusion. Of note in her medical history is an endocarditis with staphylococcus aureus, valvular and hypertensive heart disease with moderate aortic stenosis and light-grade aortic insufficiency, stage 3 renal failure. After transfusion of approx. 240 ml over 1 hour she presents rigors, hypertension and tachycardia (BP rises from 110/64 to 200/100 mmHg, P from 105 to 130/min). Temperature: 36.5 ► 37.3°C Swisstransfusion, 06.09.2013

  8. Case 2 • An 86-year-old patient with anaemia following diverticular haemorrhage (Hb 66 g/L) receives a RBC-transfusion. Medical history: endocarditis with staph. aureus, valvular and hypertensive heart disease, stage 3 renal failure. • After transfusion of approx. 240 ml over 1 hour: rigors, hypertension and tachycardia (BP rises from 110/64 to 200/100 mmHg, P from 105 to 130/min). Temperature: 36.5 ► 37.3°C • What would you do / investigate ? • check immune-haematology, check for haemolysis • chest X-ray • bacterial cultures • stop transfusion • anything else ? Swisstransfusion, 06.09.2013

  9. Case 2 • An 86-year-old patient with anaemia following diverticular haemorrhage (Hb 66 g/L) receives a RBC-transfusion. Medical history: endocarditis with staph. aureus, valvular and hypertensive heart disease, stage 3 renal failure. • After transfusion of approx. 240 ml over 1 hour: rigors, hypertension and tachycardia (BP rises from 110/64 to 200/100 mmHg, P from 105 to 130/min). Temperature: 36.5 ► 37.3°C • What would you do / investigate ? • check immune-haematology, check for haemolysis • chest X-ray • bacterial cultures • stop transfusion • administer diuretics ? Swisstransfusion, 06.09.2013

  10. Case 2 • Results: • immune-haematology: nothing particular • check for haemolysis: Bili tot. 3.9 µmol, LDH 252 IE/l • Haptoglobin 2.57 g/l • chest X-ray: not done • bacterial cultures: product cultures negative • stop transfusion: doesn’t say, but hope so (TR is classed as life-threatening ! ) • anything else ? Pro-BNP (1 hr after TR): 8753 ng/l Swisstransfusion, 06.09.2013

  11. Case 2 Classification: Severity: Imputability: TACO life-threatening (according to local HV team) probable Swisstransfusion, 06.09.2013

  12. Case 2 • And what if the patient needs further transfusions ? • Patient at risk for circulatory overload ► • limit transfusion rate to 1 ml/kg BW/h • consider premedication with diuretics • but first: check Hb ► 85 g/l after transfusion, stable conditions, so perhaps no immediate need for further transfusion Swisstransfusion, 06.09.2013

  13. Case 3 • A regional bloodtransfusionserviceisnotifiedof a grade 3 transfusionreaction in a 58-year oldpatientfollowingtransfusionof 2 RBC, classifiedas TRALI, imputability probable • symptoms: dyspneawithhypoxia 1 hour after transfusionof • 2 RBC (over 2 hours) in a patientwiththoraco-abdominal aneurysmoftheaorta. • temp. 36.7 / 36.8°C , BP 120/55 ► 135/80 mmHg, P 76/72 • Hbbeforetransfusion 97 g/l, after 139 g/l • severity: life-threatening • nofurtherinformation Swisstransfusion, 06.09.2013

  14. Case 3 • A regional blood transfusion serviceisnotifiedof a grade 3 transfusion reaction in a 58-year oldpatientfollowing transfusion of 2 RBC, classifiedas TRALI, imputability probable. Symptoms: dyspneawithhypoxia 1 hour after transfusion of 2 RBC (over 2 hours) in a patientwiththoraco-abdominal aneurysmoftheaorta. Temp. 36.7 /36.8°C , BP 120/55 ► 135/80 mmHg, P 76/72, Hb 97 g/l ► 139 g/l. Severitylife-threatening • Do youagreewiththeinitialsuspicion(probable TRALI) ? • Yes • No • Yes, but… Swisstransfusion, 06.09.2013

  15. Case 3 • A regional blood transfusion serviceisnotifiedof a grade 3 transfusion reactionthathadoccurredthedaybefore in a 58-year oldpatientfollowing transfusion of 2 RBC, that was classifiedas probable TRALI. • Symptoms: dyspneawithhypoxia 1 hour after transfusion of 2 RBC (over 2 hours) in a patientwiththoraco-abdominal aneurysmoftheaorta. Temp. 36.7 /36.8°C , BP 120/55 ► 135/80 mmHg, P 76/72, Hb 97 g/l ► 139 g/l. severitylife-threatening • Do youagreewiththeinitialsuspicion ? • Yes • No • Yes, but… Swisstransfusion, 06.09.2013

  16. Case 3 A regional blood transfusion serviceisnotifiedof a grade 3 transfusion reactionthathadoccurredthedaybefore in a 58-year oldpatientfollowing transfusion of 2 RBC, that was classifiedas probable TRALI. Symptoms: dyspneawithhypoxia 1 hour after transfusion of 2 RBC (over 2 hours) in a patientwiththoraco-abdominal aneurysmoftheaorta. Temp. 36.7 /36.8°C , BP 120/55 ► 135/80 mmHg, P 76/72, Hb 97 g/l ► 139 g/l. severitylife-threatening Other possibilities ? Allergic TR TACO TAD Respiratorydistress non transfusion-related ► More informationneeded Swisstransfusion, 06.09.2013

  17. Case 3 • Further information: • intubationnecessary due toworseningdyspnoea • Echocardiographyshowspulmonaryhypertension, normal LVEF • Pro-BNP > 4000 ng/l (post-transfusion andfollowingday, nopreviouscount) • Chest X-ray: repeatedlyno bilateral infiltrates, but signsofincreasingpulmonaryhypertension • pre-existing mild hypoxia(PaO2 9.7, reference 10-12,9 kPa) Swisstransfusion, 06.09.2013

  18. Case 3 TRALI ↔ TACO ? Swisstransfusion, 06.09.2013

  19. Case 3 Swisstransfusion, 06.09.2013

  20. Case 4 A 70-year oldpatientwithpancytopeniaofunknownoriginistransfusedwith 1 PC and 2 RBCs. After thesetransfusionsthepatientpresentedfever (temperature 37.9 ► 39.6°C), a rise in BP (108/62 ►129/75 mmHg) andheart rate (82 ► 118) In whichdirectionwouldyouinvestigate ? Bacterialinfection Haemolytic TR TACO FNHTR Other causeforfever Swisstransfusion, 06.09.2013

  21. Case 4 A 70-year oldpatientwithpancytopeniaofunknownoriginistransfusedwith 1 plateletconcentrateand 2 RBCs. After thesetransfusionsthepatientpresentedfever (temp. from 37.9 to 39.6°C), a rise in BP from 108/62 ►129/75 mmHg, P 82 ► 118 In whichdirectionwouldyouinvestigate ? Bacterialinfection Haemolytic TR TACO FNHTR Other causeforfever Swisstransfusion, 06.09.2013

  22. Case 4 A 70-year oldpatientwithpancytopeniaofunknownoriginistransfusedwith 1 plateletconcentrateand 2 RBCs. After thesetransfusionsthepatientpresentedfever (temp. from 37.9 to 39.6°C), a rise in BP from 108/62 ►129/75 mmHg, P 82 ► 118 Whichofthefollowinginvestigationswouldyou do ? Check documentation Repeat T&S pre- and post Check forhaemolysis Bacterialcultures Chest X-ray Echocardiography Check fluid balance     ? Swisstransfusion, 06.09.2013

  23. Case 4 • Results: • Documentation: nodiscrepancies • Haemolysis: bilirubine tot 43 µmol/l, LDH 150 IE/l, • haptoglobine< 0.058 g/l • Immune-haematology: • DAT pre-transfusion, monospec.: IgG 1+, ab-screen neg. • DAT post-transfusion, monospec.: IgG 1+, antibodyscreen positive ► Anti-C(onlyenzyme-enhanced) • Bacterialcultures: negative forpatient‘sbloodandbloodcomponents • Oneofthetransfused RBCs was positive for C antigen ! Swisstransfusion, 06.09.2013

  24. Case 4 • Howcome a C-positive product was issued ? • Routine pre-transfusionalantibodyscreenperformedwith 4 Coombscells was negative (noenzymeenhancedcells) • Positive antibodyscreenonlybecame evident on examiningthe transfusion reaction ► screenwith 6 cellsofwhich 2 areenzymeenhanced Swisstransfusion, 06.09.2013

  25. Case 4 Classificationlocal HV: „Althoughantibodiesonlydetectable in theenzymephaseare not usuallyassociatedwithacutehaemolysis, theclinicalpresentationandlaboratoryfindingsstronglysuggesttheoccurenceof an acutehaemolytic transfusion reaction“. Imputability „possible“ Swisstransfusion, 06.09.2013

  26. Case5 • A 77-year oldpatient in haemorrhagicshock due tolower GI-bleedingrequired massive transfusion, in thecourseifwhich he also received an FFP. After transfusion ofapprox. 30 ml, thepatientpresentedgeneralisedurticaria, swellingofthechinandlips, nodyspnoea. BP rosefrom 130/60 to 150/80 mmHg, P from 60 to 65/min. Patient has a historyofallergytopenicillin (rash) andhadgastroenteritis 4 dayspreviously. • Whatactions do youpropose ? • Stopthetransfusion • Applyantihistamines / steroids, Adrenaline • Givediuretics • Bacterialcultures Swisstransfusion, 06.09.2013

  27. Case5 • A 77-year oldpatient was admitted in haemorrhagicshock due tolower GI-bleedingand was transfusedwith FFP. After transfusion ofapprox. 30 ml, thepatientpresentedgeneralisedurticaria, swellingofthechinandlips, nodyspnoea. BP rosefrom 130/60 to 150/80 mmHg, P from 60 to 65/min. 4 dayspreviouslythepatienthadgastroenteritis. Patient has a historyofallergytopenicillin (rash). • Whatactions do youpropose ? • Stopthetransfusion • Applyantihistamines / steroids (Adrenaline) • Givediuretics • Bacterialcultures Swisstransfusion, 06.09.2013

  28. Case5 The transfusion was stopped immediately and Tavegyl, Solumedrol and Zantic were administered, with favourable effect. The immune-haematological investigations showed no incompatibility, the bacterial cultures of the product remained sterile. The TR was classified as: Allergic TR, anaphylactoid , grade 1 (or mild allergic ?) Swisstransfusion, 06.09.2013

  29. Case5 • 3 dayslater, the same patientreceived a RBC. This time, towardsthe end ofthetransfusion he developsdyspnoea, swellingenoral, ofthefaceandeyelids. Nohaemodynamicproblems. Hbcount 101 ► 122 g/l • Suggestedinvestigations: • chest X-ray • IgA, anti-IgAandtryptase • Bacterialcultures • Immune-haematology Swisstransfusion, 06.09.2013

  30. Case5 • 3 dayslater, the same patientreceived a RBC. This time, towardsthe end ofthetransfusion he developsdyspnoea, swellingenoral, ofthefaceandeyelids. Nohaemodynamicproblems. Hbcount 101 ► 122 g/l • Suggestedinvestigations: • chest X-ray • IgA, anti-IgAandtryptase • Bacterialcultures • Immune-haematology Swisstransfusion, 06.09.2013

  31. Case5 • 3 dayslater, the same patientreceived a RBC. This time, towardsthe end ofthetransfusion, he developsdyspnoea, swellingenoral, ofthefaceandeyelids. Nohaemodynamicproblems. Hbcount 101 ► 122 g/l • Results: • chest X-ray • IgA, anti-IgAandtryptase: withinthe normal range • Bacterialcultures (product) negative • Immune-haematologynoparticularfindings Swisstransfusion, 06.09.2013

  32. Case5 • Diagnosis / futuremanagement: • Classification: anaphylactoid TR • Severity: grade 1 • Imputability: probable • Considerpremedicationwithantihistamines. • In caseofre-occurrenceofallergic TRs, discussadministrationofwashedcellularbloodcomponentswithblood transfusion service. Swisstransfusion, 06.09.2013

  33. Case 6 Blood products are ordered daily from a haematology ward using a form that lists all the patients currently on the ward with their respective blood counts. The number of required RBCs or PCs is marked in the corresponding column. This particular day, the blood bank staff member responsible for preparing the blood products missed a line and issued a PC for patient AB instead of patient ZZ, although no blood products were ordered for AB that day. The delivery arrived on the ward round about lunch time; several components were sent together and the number of staff was reduced. Swisstransfusion, 06.09.2013

  34. Case 6 The nurse responsible would like to get the platelet transfusion done before lunch. It is her first day back at work after a period of absence and she omits to check the prescription and also doesn‘t look at patient AB‘s blood count. The PC is administered to the patient AB without any problems. After a while, the ward notices that the PC ordered for the patient ZZ has not yet been delivered. On checking with the lab, the error comes to light. Patient AB had a platelet count of > 200 and did not need the transfusion. Swisstransfusion, 06.09.2013

  35. Case 6 • 2 deviations: • PC issuedforthewrongpatient • Administration ofthe PC withoutcheckingtheprescriptionand also withoutnoticingthattransfusing a patientwhohad a normal plateletcount was not feasible. • Anysuggestionsforcorrectivemeasures ? • Remodellingofthe order form, so thatitis not so easy to miss a line • No transfusion withoutprescription / checkingtheprescription Swisstransfusion, 06.09.2013

  36. Case 6 Old list Swisstransfusion, 06.09.2013

  37. Case 6 Columns for number of requested BP is closer to name of patient New list Swisstransfusion, 06.09.2013

  38. Case 7 Male donor, born in 1984, about to undertake his first platelet apheresis donation. He had donated whole blood on several occasions, the last time a few years ago. On the donor questionnaire he noted chronic sinusitis, no signs at the moment. No other problem comes up during the pre-donation check and he is considered fit to donate. During the first re-infusion (flow rate 150 ml/min), his lips start tingling, shortly after he has a sensation of trembling on his chest. Swisstransfusion, 06.09.2013

  39. Case 7 • Male donor, born in 1984, abouttoundertakehisfirstplateletapheresisdonation. He haddonatedwholeblood on severaloccasions, the last time a fewyearsago. On thedonorquestionnaire he notedhavingchronicsinusitis, nosignsofexacerbationatthemoment. He isconsidered fit todonate. • Duringthefirstre-infusion, flow rate 150 ml/min, hislipsstarttingling, shortly after he has a sensationoftrembling on hischest. • What do youthinkcouldbewrongandwhatwouldyou do ? • first, mild signsofcitratetoxicity ► theflow rate isreducedto 100 ml/min, whichhelpsstraightaway. The donorisgiven 2 soft tabletsofcalcium (Calcimagon) Swisstransfusion, 06.09.2013

  40. Case 7 During the second re-infusion, the sensations of tingling and trembling appear again, a bit milder, this time combined with slight dyspnoea, followed by a dry cough and red eyes (red conjunctiva). Would you continue or stop the apheresis ? The flow rate is reduced further to 70 ml/min and the donor feels a bit better. The third re-infusion caused recurrence of all symptoms plus oedema of both eyelids. The apheresis is stopped after a total duration of 24 minutes. Swisstransfusion, 06.09.2013

  41. Case 7 The symptoms persisted for over an hour after breaking off the apheresis. The donor also had to vomit once. He was treated with 500 mg of Solumedrol and Tavegyl iv and inhalations with Dospir for persistent bronchospasm. The donor had gone back to work, but had to leave and go home about 2 hours later. By late evening the symptoms had receded completely and the donor was able to go to work the next day free of complaints. How would you classify the reaction ? Swisstransfusion, 06.09.2013

  42. Case 7 • Generalised allergic (anaphylactoid) reaction • Severity: grade 2 • Caused by citrate ? An other solution ? Plasticisers ? • It turned out the donor had an atopic disposition with a history of various allergic manifestations, including asthma. However, he had neither mentioned this on the questionnaire nor during the pre-donation check. He had also taken 2 soft tablets of calcium 2 hours before the donation. Swisstransfusion, 06.09.2013

  43. Case 7 • Whatcanwelearnfromthiscase ? • Questioneveryfirst-time apheresisdonordirectly on a possiblehistoryof allergies. • Assessmentofthedeputychiefmedicalofficeratthetransfusionservice: • Blood productscontainingplasmathatweredonatedbydonorswithatopicdispositioncanpossiblycauseallergicreactions in recipients ► donorswhosebloodproductscauseallergicreactions in patientsmayneedtobedeferredfromdonationorat least barredforthespecificpatient. Swisstransfusion, 06.09.2013

  44. Case 8 • Due to previous clopidogrel-medication, a 47-year old patient receives one pooled PC post-operatively after successful and uneventful mitral valve reconstruction. • 5 minutes after the beginning of the transfusion he presents: • shock, MAP drops from >60 to <40 mmHg • hypoxia • The patient has to be re-intubated. • Which is your first assessment? • 1) hemorrhagic shock 4) TAD • 2) anaphylactic shock 5) TRALI • 3) septic shock 6) don’t know Swisstransfusion, 06.09.2013

  45. Case 8 • Due to previous clopidogrel-medication, a 47-year old patient receives one pooled PC post-operatively after successful and uneventful mitral valve reconstruction. • 5 minutes after the beginning of the transfusion he presents: • shock, MAP drops from > 60 to < 40 mmHg • hypoxia • The patient has to be re-intubated. Which is your first assessment ? 1) hemorrhagic shock 2) anaphylactic shock 3) septic shock 4) TAD 5) TRALI 6) don’t know Swisstransfusion, 06.09.2013

  46. Case 8 Effusion of copious/massive amount of fluid from tubus indicating pulmonary oedema Chest X-ray shows bilateral infiltrates. Worsening of the respiratory situation necessitates re-installment of ECMO (extracorporealmembraneoxygenation). The patient requires high dosed catecholamine treatment over the next 2 days Swisstransfusion, 06.09.2013

  47. Case 8 • Effusion of copious/massive amount of fluid from tubus indicating pulmonary oedema. Chest X-ray shows bilateral infiltrates. • Worsening of the respiratory situation necessitates re-installment of ECMO (extracorporealmembraneoxygenation). • The patient requires high dosed catecholamine treatment over the next 2 days. • Which investigations would you propose ? • Check T&S, check for haemolysis • Echocardiography, post-operative bleeding ? • Bacterial cultures (patient and product) • IgA • HLA- /HNA-antibodies • Donor histories Swisstransfusion, 06.09.2013

  48. Case 8 • Effusion of copious/massive amount of fluid from tubus indicating pulmonary oedema. Chest X-ray shows bilateral infiltrates. • Worsening of the respiratory situation necessitates re-installment of ECMO (extracorporealmembraneoxygenation). • The patient requires high dosed catecholamine treatment over the next 2 days. • Which investigations would you propose ? • Check T&S, check for haemolysis • Echocardiography, post-operative bleeding ? • Bacterial cultures (patient and product) • IgA • HLA- /HNA-antibodies • Donor histories Swisstransfusion, 06.09.2013

  49. Case 8 • Results: • IH: pre- and post transfusion: BG A pos, T&S negative, DAT negative, crosscheck + • Echo: “good”. Post-op ejection fraction was 60%. The mitral valve is functioning fine, cardiologists exclude cardiac origin of the pulmonary oedema • HLA-ab: HLA-ab class I and II negativ (Luminex) • HNA-ab: HNA-ab negative (Flow-GIFT/SASGA) • for all 5 donors and patient • Donors: 4 female, one male (number of donations 10-62, no known complications) • Bacteriology and IgA not done Swisstransfusion, 06.09.2013

  50. Case 8 • What is your assessment now ? • 1) haemorrhagic shock • 2) anaphylactic shock • 3) septic shock • TAD • TRALI • still don’t know Swisstransfusion, 06.09.2013

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